Restoration of pull-out strength of the failed pedicle screw: biomechanical comparison of calcium sulfate vs polymethylmethacrylate augmentation.

OBJECTIVE: The aim of the present study was to compare calcium sulfate (CAS) and polymethylmethacrylate (PMMA) bone cements used for the augmentation of a failed pedicle screw with biomechanical pull-out strength (POS) testing. METHODS: Thirty lumbar vertebrae were harvested from 6 calves and bone mineral densities (BMD) were measured. Primary polyaxial pedicle screws were randomly inserted and pulled out and the POSs of the specimen were recorded. For revision, specimens were randomly assigned to the CAS-augmented pedicle screws group (Group 1) or PMMA-augmented pedicle screw group (Group 2). Pull-out tests were repeated to compare both groups. RESULTS: Mean BMD of the specimens was 1.006 ± 0.116 g/cm(2). There were no statistically significant differences between BMD results of the two groups (p=0.116). For Group 1, mean POS of primary screws was 2,441.3 ± 936.4 N and was 2,499.5 ± 1,425.1 N after CAS augmentation, demonstrating no statistically significant difference (p=0.865). In Group 2, mean POS of the primary screws was 2,876.6 ± 926.6 N and significantly increased to 3,745.5 ± 1,299.2 N after PMMA augmentation (p=0.047). There was also a significant difference in mean POS between the CAS and PMMA groups (p=0.026). CONCLUSION: Although CAS augmentation facilitates a revision screw POS as strong as that of primary screws, it is not as strong as PMMA augmentation.

Extracorporeal shock waves in articular cartilage defects in the rats.

Thirty adult Sprague-Dawley rats were used to assess the nature of healing tissues in hyaline cartilage defects and to compare the healing in defects treated with shock waves, with those in defects without treatment. A 2 × 2 mm cartilage defect with exposed cancellous bone was created in a nonweight-bearing area of each medial femoral condyle. Each right knee defect was received extracorporeal shock waves (Swiss Dolorclast) of 500 impulses in 5 min at 2 bar (comparative to 0.09 mJ/mm(2)), and the left knee defects were assigned as controls. The rat groups were sacrificed at 6 and 12 weeks postsurgery. Sections from each knee were stained with hematoxylin-eosin to analyze synovial adhesion, synovial thickness, bone maturation, and chondroid metaplasia and with masson trichrome to analyze collagen fiber intensity. There was not a significant difference found between the study and control groups (P > 0.05). Extracorporeal shock waves did not effect healing of the chondral defects.

Prospective evaluation of the functional and anatomical results of arthroscopic repair in small and medium-sized full-thickness tears of the supraspinatus tendon.

OBJECTIVE: The purpose of this study was to analyze the relation between tendon integrity and functional results following the arthroscopic treatment of small- and medium-sized rotator cuff tears. METHODS: Arthroscopic repair was performed on 26 consecutive patients (21 women, 5 men;mean age: 55.9 years; range: 33-72 years) with small- and medium-sized tears of the supraspinatus tendon. Patients were postoperatively evaluated at 12 and 24 months using the Constant and UCLA functional outcome scores and ultrasound examinations. RESULTS: The supraspinatus tendon did not heal in nine patients (34.6%) and was partially healed in three (11%), 12 months after surgery. Mean postoperative Constant and UCLA scores of these patients were 73.1 and 27.8, respectively, which were not significantly different from those with an intact tendon on the final follow-up (Constant: 78 and UCLA: 30; p=0.107 and p=0.164). Both rating systems reflected significant improvement with treatment (p<0.01). The mean age of patients with a re-tear was 66.8 years, which was significantly higher than those with an intact repair (54 years; p<0.01). CONCLUSION: The arthroscopic repair of small and medium-sized supraspinatus tendon tears yields good long-term results independent of tendon integrity. Healing potential may be decreased with increased age.

[Unicondylar knee arthroplasty in medial unicompartmental osteoarthritis: technical faults and difficulties]. / Diz medial osteoartritinde unikondiler diz protezi: Teknik hatalar ve sorunlar.

OBJECTIVES: The aim of this study is to evaluate both the technical problems of surgery and the clinical and radiologic outcomes of patients treated with unicondylar knee arthroplasty. PATIENTS AND METHODS: Forty-one unicondylar knee prosthesis were performed in 40 patients (3 males, 37 females; mean age 58.2 years; range 44 to 76 years) diagnosed with unicompartmental knee osteoarthritis. Technical problems encountered during surgery were noted. For evaluation of clinical outcomes, the Hospital for Special Surgery (HSS) knee score and WOMAC score were used. Radiologic evaluations were performed using the Oxford Knee Group criteria. RESULTS: The radiologic evaluation determined there was more than 10 degrees varus-valgus malposition in eight patients, more than 2 mm medial tibial overhang in seven patients, the insertion of a femoral component in extension in one patient, and joint distraction in one patient. The patient with joint distraction underwent a total knee replacement after six months because of progressive pain. The mean HSS knee score improved 21 points; perfect results were obtained in 33 patients and good results in seven patients. The mean postoperative WOMAC score was reduced by 18 points, with perfect results in 33 patients, good results in six patients and a moderate result in one patient. The mean follow-up was 19 months (range 9-42). CONCLUSION: Unicondylar knee arthroplasty is a surgical treatment method with a long-term recovery and high frequency of technical faults. Minor errors diagnosed on radiographs do not have an effect on early clinical results. Unicondylar knee arthroplasty is a good alternative surgical technique for appropriately selected patients with medial unicompartmental knee osteoarthritis.

[The effects of two different fixation methods on femoral bone tunnel enlargement and clinical results in anterior cruciate ligament reconstruction with hamstring tendon graft]. / Hamstring tendon otogrefti ile yapilan ön çapraz bag rekonstrüksiyonunda iki farkli tespit yönteminin femoral kemik tünel genislemesi ve klinik sonuçlar üzerine etkisi.

OBJECTIVES: We investigated the effects of anatomic and non-anatomic tunnel fixations on femoral tunnel widening and clinical results in anterior cruciate ligament (ACL) reconstructions. METHODS: We retrospectively evaluated 35 patients who underwent arthroscopic ACL reconstruction with quadrupled hamstring tendon graft. Fixation was performed in the tunnel using the transcondylar RigidFix pin (group 1) in 18 patients (mean age 32 years), and from outside the tunnel using the EndoButton-CL device (group 2) in 17 patients (mean age 30 years). The patients were assessed using the IKDC (International Knee Documentation Committee) and Lysholm knee scores and tunnel widening was assessed by computed tomography. Ligament laxity was measured bilaterally using the Rolimeter knee tester. The mean follow-up was 24 months (range 21 to 38 months) in group 1, and 24.6 months (range 12 to 36 months) in group 2. RESULTS: The two groups were similar with respect to age and sex distribution, operated side, the size of the tunnel created, and follow-up period (p>0.05). Postoperative knee scores did not show a significant difference (p>0.05). There was marked and excessive tunnel enlargement in 14 patients (77.8%) in group 1, and in 15 patients (88.2%) in group 2, with no significant difference between the two groups (p>0.05). Ligament laxity exceeded 3 mm in eight patients (44.4%) in group 1, and in three patients (17.7%) in group 2 (p<0.001). There was no relationship between tunnel widening and ligament laxity (p>0.05; r=0.175 and r=-0.01 for group 1 and group 2, respectively). CONCLUSION: Our results suggest that differences in the localization of the tunnel fixation have no effect on tunnel enlargement and that joint laxity may be affected by biomechanical properties of fixation materials.

Plating after lengthening (PAL): technical notes and preliminary clinical experiences.

INTRODUCTION: Shortening the period of time for the external fixator after limb lengthening decreases the complication rate and increases the patient satisfaction. MATERIAL AND METHOD: We describe the plating after lengthening (PAL) as a new technique on five patients with limb length discrepancy (1 femoral, 4 tibial) who had lengthening procedure with Ilizarov technique. The mean amount of lengthening was 50 mm. The mean lengthening period was 100 days (5-135 days). When the lengthening period ended, the locking compression plate was applied percutaneously by using the technique of minimal invasive plate osteosynthesis, and the Ilizarov external fixator was removed. RESULTS: The fixator-free period was achieved at the beginning of the consolidation phase, except in two patients, which were delayed for plating because of pin-tract infection. No complication was encountered except in one patient who had limited flexion of knee joint. There was no need for blood transfusion. DISCUSSION: The PAL, which shortened the period of time for the external fixator, was an easy and safe method for the fixation of the bone after limb lengthening.

Combined ulnar and carpal tunnel syndrome caused by pigmented villo-nodular tenosynovitis: a rare case.

Pigmented villo-nodular synovitis/tenosynovitis (PVNS) is a rare cause of combined ulnar and median nerve compression neuropathy at the wrist. In our case, a 53-year-old house-wife had sensorial and motor complaints at her left hand. In clinical examination, painless soft tissue mass was palpated at her wrist and both the tenar and hypotenar muscles were atrophic. Electromyography showed prolonged distal latencies for median and ulnar nerve. A space-occupying soft tissue lesion was revealed in magnetic resonance imaging. Carpal tunnel and Guyon canal were released and lesion was excised. PVNS was confirmed by histopathological examination. If compression neuropathy of medial and ulnar nerves together is caused by a space-occupying lesion, PVNS should be considered in etiology.

Necrotizing soft-tissue infection of a limb: clinical presentation and factors related to mortality.

BACKGROUND: Necrotizing fasciitis is a rare and often fatal soft-tissue infection. Prompt diagnosis and immediate aggressive surgical debridement of all compromised tissues are critical to reducing morbidity and mortality in these rapidly progressive infections. The purpose of this study was to analyze the clinical presentation and evaluate factors that determine mortality associated with this uncommon surgical emergency. METHODS: The study retrospectively investigated the medical records of 22 patients who were diagnosed and treated for necrotizing fasciitis of the lower extremity, 14 of whom had involvement of the foot (nine patients) or foot and ankle (five patients) at our hospital. The data collected for each of the 22 patients were age, sex, underlying systemic factors, location of infection, duration of symptoms, portal of entry of infection, initial diagnosis on admission, physical, radiographic and laboratory findings, microbiological cultures, the type of therapy used (debridement or amputation), treatment outcome, and number of days in the hospital. RESULTS: A total of 23 extremities of 22 consecutive patients with necrotizing fasciitis who underwent surgical debridement or amputation were retrospectively reviewed. Radical surgical debridement was done in 16 extremities initially, and this treatment was repeated a mean of two times (range one to four debridements) to completely remove all the necrotic tissue. Nine patients (41%) required below-knee or above-knee amputation. There were three deaths, one related directly to sepsis and organ failure, one due to gastrointestinal hemorrhage, and one caused by pulmonary embolism. There were no significant differences between patients who had the amputations and those who did not with respect to mortality rate or age (p = 0.538 and p = 0.493, respectively). Those who died were significantly older than the survivors (p = 0.038). CONCLUSIONS: The diagnosis of necrotizing fasciitis should be considered for any individual who has unexplained limb pain, especially if that person has diabetes mellitus or chronic liver disease. There was no difference in mortality rates between patients with or without amputation. The primary treatment is early and aggressive debridement of involved skin, subcutaneous fat, and fascia.

Hallucal sesamoid osteonecrosis: an overlooked cause of forefoot pain.

Four cases of osteonecrosis of hallucal sesamoids are reported here. Surgical excision of necrotic sesamoid tissue yielded satisfactory results, with the patients reporting no residual pain. Although it has not been frequently addressed in the literature, avascular necrosis of the sesamoid bones should be considered in the differential diagnosis of persistent forefoot pain.

Time dependent changes in patellar tracking with medial parapatellar and midvastus approaches.

The aim of this study was to compare the alteration of patellar tracking by time, which was performed through two different approaches: midvastus and medial parapatellar. Twenty-one patients undergoing simultaneous bilateral primary total knee replacements were randomized prospectively to perform the surgery via a medial parapatellar approach on one knee and midvastus approach on the other knee. All of the patellae were resurfaced. Preoperative, early and late postoperative (mean 22 month) skyline views of the patellae were taken. We found that preoperative 2.24 degrees lateral tilt of patella had not changed by time at the midvastus side (2.95 degrees and 2.57 degrees ). Moreover, preoperative 0.48% lateral subluxation of the patella for midvastus approach had not changed (1.48% and 1.67%). Although 2.19 degrees patellar lateral tilt had not significantly changed at the early postoperative period, which was performed via medial parapatellar approach, there had been a significant increase to 5.38 degrees by time (P=0.037) compared to the preoperative radiographs. Additionally, the preoperative lateral subluxation of the patella (0.57%) at the medial parapatellar side had increased to 5.43% at the early (P=0.009) and 5.62% at the late (P=0.012) postoperative measurements. Midvastus approach is superior to medial parapatellar approach concerning the late patellar tracking.

Arthroscopic treatment of solitary benign intra-articular lesions of the knee that cause mechanical symptoms.

PURPOSE: Most cases of knee locking and giving-way are caused by meniscal tears, loose bodies, or chondral lesions. Intra-articular benign tumors or tumor-like lesions can present with symptoms that resemble acute mechanical derangement. From a database of 2,200 arthroscopic interventions, 19 cases of intra-articular masses that presented with catching and locking symptoms in the knee were retrospectively analyzed. TYPE OF STUDY: Case series. METHODS: Our review revealed 33 patients with benign intra-articular masses in the knee joint. Nineteen of these individuals had sought medical attention for mechanical symptoms of catching or locking. The other 14 patients had a variety of symptoms including pain, swelling, and limitation of knee motion, but did not have mechanical symptoms. Age, sex, history of trauma, knee pain and effusion, medical illnesses, physical examination, arthroscopic findings, and pathologic findings were noted. RESULTS: The average age of the 6 male and 13 female patients was 37.5 years (range, 18 to 58 years). Preoperative magnetic resonance imaging confirmed the diagnosis in 7 cases and 12 cases were diagnosed during knee arthroscopy. The mean follow-up time after surgery was 52.5 months (range, 6 to 120 months). Pathologic examination of the lesions revealed 15 cases of localized pigmented villonodular synovitis (79%), 1 lipoma arborescens (5%), 1 pseudocyst (5%), and 2 nonspecific synovial masses (11%). None of the lesions showed malignant transformation. CONCLUSIONS: Solitary benign intra-articular lesions should be considered a rare cause of mechanical knee symptoms. Localized pigmented villonodular synovitis originating from the extensor mechanism or fat pad is the most common solitary intra-articular mass lesion in the knee and usually arises in the patellofemoral compartment. Recurrence has not occurred in our series, which includes 14 of 19 patients with greater than 24 months follow-up. LEVEL OF EVIDENCE: Level IV.

Primary clear cell sarcoma of rib.

Clear cell sarcoma (malignant melanoma of soft tissues) is a very rare soft tissue neoplasm. It generally arises in tendons and aponeuroses. Although metastasis of malignant melanoma to bone is not uncommon, primary clear cell sarcoma of bone is an extremely rare neoplasm. To our knowledge five cases have been reported in the English literature. We present a case of primary clear cell sarcoma of bone in a 28-year-old woman arising in the left ninth rib. We treated the patient with total excision of the mass and postoperative radiotherapy. The patient is alive and well without local recurrence or distant metastasis at 33 months after surgery.

[A comparison between single- and two-staged bilateral total knee arthroplasty operations in terms of the amount of blood loss and transfusion, perioperative complications, hospital stay, and cost-effectiveness]. / Iki tarafli total diz artroplastisini tek veya iki seansta uygulamanin kanama ve transfüzyon miktari, perioperatif komplikasyon, hastanede kalis süresi ve maliyet açisindan karsilastirilmasi.

OBJECTIVES: We compared bilateral total knee arthroplasty (TKA) operations performed at a single session or at two separate sessions with respect to perioperative complications, the amount of blood loss and transfusion, the length of hospital stay, and the overall cost. METHODS: The study included 39 patients (34 females, 5 males; mean age 68.1 years; range 52 to 88 years) and 16 patients (13 females, 3 males; mean age 66.8 years; range 52 to 83 years) who underwent bilateral TKA for osteoarthritis at a single session and at two separate sessions, respectively. Staged operations were interspersed with a mean interval of 8.3 months (range 2 to 24 months). The two groups were compared with respect to perioperative complications, the amount of blood loss and transfusion, the length of hospitalization, and the overall cost. RESULTS: The amount of blood loss and transfusion, the length of intensive care unit stay, and the occurrence of perioperative complications did not differ significantly between single- and two-staged operations (p>0.05). However, the mean length of hospital stay (10.48 days versus 17.19 days; p=0.01) and the mean overall cost (p=0.03) were significantly less in single-staged operations. Perioperative complications accounted for 12.8% (n=5) and 25% (n=4) in single- and two-staged operations, respectively, all of which developed in patients who had a preexisting cardiologic disease. CONCLUSION: In view of its advantages, single-staged bilateral TKA seems to be an appropriate alternative in selected patients.

Iatrogenic medial dislocation of hallucal sesamoids with hallux varus in an adolescent.

BACKGROUND: Iatrogenic hallux varus is a rare deformity linked to bunion surgery at late adult age. Here reported is the first adolescent case of acquired hallux varus and medial dislocation of both sesamoid bones. CASE REPORT: The patient had had a surgical intervention under his first metatarsophalangeal joint when he was 10 years old. Correction of the deformity with a tendon transfer and medial capsular release alone-as was recommended for adults-was impossible in this adolescent, 8 years after the index surgery. Excision of the contracted medial structures and repair of the lateral retinaculum of the fibular sesamoid obtained a perfect correction of the dislocated sesamoid bones.

Tunnel enlargement after arthroscopic anterior cruciate ligament reconstruction: comparison of bone-patellar tendon-bone and hamstring autografts.

Bone tunnel enlargement associated with anterior cruciate ligament (ACL) reconstruction has recently become a topic of interest in the literature. This association was examined, along with the effect of femoral and tibial tunnel enlargement on the clinical results of ACL reconstruction performed with either bone-patellar tendon-bone (BPTB) or hamstring (HST) autografts. Forty-six patients underwent arthroscopic ACL reconstruction (23 receiving BPTB autograft and 23 HST) between March 1999 and July 2001. Thirty patients (13 receiving BPTB autograft and 17 HST) completed the last clinical and radiologic evaluations and were included in the study. The mean age of patients in the HST group was 29.8 years (range 18-39) and that in the BPTB group was 27.6 years (range 20-37). The mean follow-up period was 24.6 months (range 12-36) in HST group and 18.5 months (range 12-40) in BPTB group. The effect of tunnel enlargement on the clinical results was evaluated by comparing preoperative and postoperative Lysholm, Tegner, and International Knee Documentation Committee scores and ligament laxity measurements between and within the groups. Postoperative femoral and tibial tunnel diameters in both groups were significantly larger than their corresponding preoperative tunnel diameters. In an intergroup evaluation, the enlargement of the tibial tunnel was similar in both groups (P=.556), but the femoral tunnel diameter was significantly larger in the HST group than in the BPTB group (P>.001). Preoperative laxity of the knees significantly improved after the operations in both groups, but no difference between the groups was evident at the final follow-up visit. No correlation between tunnel widening and the clinical results of the BPTB and HST procedures was observed.

Synovial cysts of proximal tibiofibular joint causing peroneal nerve palsy: report of three cases and review of the literature.

INTRODUCTION: Synovial cyst of the proximal tibiofibular joint is a very rare condition, for which there is no consensus regarding treatment. CASE PRESENTATION: We present three patients who had synovial cysts of proximal tibiofibular joint that caused peroneal nerve palsy. We discuss the special features of synovial cysts and review the literature. CONCLUSION: We consider the best treatment of synovial cysts originating from proximal tibiofibular joint and causing peroneal nerve palsy to be total surgical removal as soon as possible after the diagnosis is made. It should be kept in mind that despite surgical treatment the neurological symptoms may not recover.

The timing of tourniquet release and its influence on blood loss after total knee arthroplasty.

We performed a prospective, randomized study on 76 patients (82 knees) scheduled for total knee arthroplasty to determine the effect of tourniquet release and hemostasis on the peri- and postoperative blood loss. Patients were randomly divided in two groups. Posterior cruciate retaining tricompartmental total knee prostheses were used in all. In group 1, the tourniquet was deflated intraoperatively after the prosthetic components were settled and hemostasis was done. In group 2, the tourniquet was released after the wound was closed and a compressive bandage was applied. Mean blood drainage was 880.85 ml (320-1,315) in group 1 and 745.36 ml (220-1,175) in group 2 ( p=0.03). The mean number of blood transfusions given, hemoglobin and hematocrit values, operation time, and tourniquet time were similar in both groups. Intraoperative tourniquet release and hemostasis does not reduce total blood loss in total knee arthroplasty.

Benign noninfectious subcutaneous emphysema of the hand.

A 17-year-old girl presented pain and subcutaneous crepitation in the left hand. Because of lack of systemic symptoms, non-infectious cause was considered. Radiographic and magnetic resonance imaging revealed subcutaneous emphysema. A chest x-ray was reported as normal but chest computerised tomography revealed pneumomediastinum. On the third day of the hospitalisation, subcutaneous emphysema spread to arm, shoulder, head, left hemithorax, back, bilateral supraclavicular, cervical, submandibular and periorbital regions. Pneumomediastinum and subcutaneous emphysema disappeared during 6 weeks of follow up with conservative methods. This might have prevented unnecessary surgical intervention. This report demonstrates that benign non-infectious subcutaneous emphysema of the hand due to pneumomediastinum should be kept in mind in hand surgery.

Type 4 median nerve entrapment in a child after elbow dislocation.

UNLABELLED: CASE STUDIED: Median nerve entrapment is a rare, serious complication of elbow dislocation. We report a Type 4 median nerve entrapment after elbow dislocation in a 10-year-old boy. Radiologically Matev's sign and a new radiological finding-a sclerotic tunnel at the lateral side of the olecranon-were seen. TREATMENT: The patient was treated by excising the damaged segment and reanastomosing the nerve 13 months after the injury.

[Arthroscopic capsular release for frozen shoulder]. / Donmus omuz hastaliginin tedavisinde artroskopik kapsüler gevsetme.

OBJECTIVES: This study was designed to evaluate the results and technical considerations of arthroscopic capsular release of the glenohumeral joint in frozen shoulder disease. METHODS: Arthroscopic capsular release was performed in 16 patients (11 women, 5 men; mean age 51 years; range 40 to 60 years) unresponsive to physical therapy. The affected shoulder was on the right in 10 patients, and on the left in six, being on the dominant side in 12 patients. The duration of the patients' complaints ranged from six to 24 months. Preoperatively, the mean forward flexion was 92 degrees, external rotation was 14 degrees; the ranges of internal rotation were the trochanter in four patients, the gluteal region in seven patients, the lumbosacral region in one patient, the L3 level in one patient, and T12 level in three patients. Functional evaluations were made according to the Constant scoring system. The mean follow-up was 17.3 months (range 12 to 30 months). RESULTS: Postoperatively, the mean forward flexion and external rotation increased to 135 and 27 degrees, respectively. Internal rotation reached the gluteal region in two patients, the lumbosacral region in two patients, the L3 level in two patients, T12 level in nine patients, and the interscapular region in one patient. The mean Constant score improved by 47 points. CONCLUSION: Arthroscopic capsular release is a safe and effective surgical procedure in the management of frozen shoulder disease unresponsive to conservative treatment.